What is the methodology for calculating tiers in the CBHPM?

The Brazilian Hierarchical Classification of Medical Procedures, or CBHPM, developed by the Brazilian Medical Association (AMB) in 2003, arose to meet the need to value physicians’ work within the private healthcare system.

Before it was implemented, the amounts assigned to procedures were frequently adjusted based on unilateral decisions by payers, which caused distortions, undervaluation of the medical act and direct impacts on the quality of care provided.

In this article, learn the details of the methodology for calculating tiers in the CBHPM.

List of requirements

Procedures are coded and organized into four major chapters:

• General procedures.

• Clinical procedures.

• Surgical and invasive procedures.

• Diagnostic and therapeutic procedures.

Each procedure is classified by its degree of complexity into 14 tiers, numbered 1 to 14. Each tier, in turn, is subdivided into three levels, A, B and C, which refine the ranking according to the technical and care effort involved.

To apply this methodology for calculating and reviewing tiers in the CBHPM, a careful list of requirements must be followed, each adding points according to the complexity of the criterion. Understand the requirements and how their points are distributed (not all criteria apply to all procedures).

Physician training and learning curve

• Low complexity: 4 points.

• Medium complexity: 6 points.

• High complexity: 8 points.

Preoperative preparation

• Low complexity (outpatient): 3 points.

• Medium complexity (prior clinical evaluation or evaluation by another specialty): 4 points.

High complexity (prior interventions lasting more than one day or evaluations that influence technical decisions): 5 points.

Preparation for the surgical act

Includes complex patient positioning, the need for specific equipment or anesthetic clearance.

• Up to 30 minutes: 2 points.

• From 30 minutes to 1 hour: 4 points.

• More than 1 hour: 5 points.

Average duration of the surgical act

(from incision to completion of the suture)

• Less than 1 hour: 1 point.

• Up to 2 hours: 2 points.

• Up to 4 hours: 4 points.

• More than 4 hours: 8 points.

Intraoperative risk of the procedure

• Low risk: 2 points.

• Medium risk: 4 points.

• High risk: 8 points.

Subsequent hospital care

• Early discharge or no relevant care in the first 12 hours: 1 point.

• Simple care, with discharge on the first postoperative day: 2 points.

• Medium-complexity care in the following days: 3 points.

Intensive care, including ICU or a need for more than one hour of clinical/nursing care: 4 points.

Postoperative care outside the hospital

• Dressing, suture removal and final evaluation within one month: 1 point.

• Multiple evaluations within one month: 2 points.

Multiple evaluations extending beyond four months: 4 points.

Risk of complications and lawsuits

• Low: 1 point.

• Medium: 2 points

• High: 4 points.

Radiation exposure

• From 1 to 6 exposures: 2 points.

• From 7 to 16 exposures: 3 points.

• 17 or more exposures: 4 points.

Point composition

The total sum of points defines the tier and its subdivision in the CBHPM, according to the official classification table. Each scoring range corresponds to a specific tier, from 3A to 13C, reflecting more accurately the technical complexity, the risk and the care effort of the procedure.

This methodology seeks to reduce historical distortions, promote greater fairness in physician pay and create a technical reference standard for negotiations in the private healthcare system.